Thursday, January 1, 2009

French Psychiatry's Initial Reception of Bayle's Discovery of General Paresis of the Insane

During the nineteenth century general paresis of the insane emerged as a new psychiatric disorder which was extremely common and completely devastating. While retrospective studies have found earlier instances of what may have been the same disorder, the first clearly identified examples of paresis among the insane were described in Paris after the Napoleonic Wars.1 General paresis most often struck people (men far more frequently than women) between twenty and forty years of age. Within a matter of months to a few years after the appearance of the first symptoms, it reduced its victims to a state of dementia and profound weakness. No treatment was known, and patients uniformly died. During the nineteenth century its prevalence came to be widely recognized. By 1877, for example, the superintendent of an asylum for men in New York reported that in his institution this disorder accounted for more than twelve percent of the admissions and more than two percent of the deaths.2 In the twentieth century, with the development of accurate diagnostic methods, general paresis was definitively linked to syphilis and with the development of effective treatment methods for syphilis it has become rare.

While historians have recently effectively applied social, political and economic analyses to psychiatry's past, they have largely ignored the history of general paresis. When they have discussed this disorder, they have treated it as an example of psychiatry's success in defining and explaining disease.3 The history of general paresis of the insane is, however, richer in historical ironies and more revealing of social and intellectual conflicts than such accounts suggest. Ackerknecht, for example, noted that while Antoine-Laurent-Jesse Bayle's "discovery of progressive paralysis as a separate disease picture (in 1822)... was of immense importance," Bayle was nonetheless "caused to leave psychiatry altogether."4Why was there such a contrast between Bayle's fate and the ultimate glorification of his discovery, one might ask. For some like Jacques Postel and Rene Semelaigne this question does not arise because they deny that Bayle was "caused to leave psychiatry." Instead they argue that Bayle was never seriously interested in psychiatry and that he left the field at the first opportunity. This view is, however, implausible. While Bayle may never have had an interest in treating the mentally ill, he was a dedicated researcher. As such it is hard to imagine him abruptly and voluntarily abandoning a field in which he had just made what he regarded as an epochal discovery. Further, as Semelaigne noted, Bayle always followed debates over general paresis and was always ready to defend his priority in the discovery of that disorder.5 Jan Goldstein has proposed a purely sociological explanation for Bayle's departure from psychiatry. Noting that Bayle, was a student of Antoine-Athanase Royer-Collard, a rival of Jean-Etienne-Dominique Esquirol, who was the leader of that circle of psychiatrists which established psychiatry as a profession in France, Goldstein argues that "when Royer-Collard died in 1825, Bayle was without a protector, and Esquirol showed no inclination to take the talented young man, under his wing."6 Goldstein, however, fails to ask why Esquirol would not have wanted to adopt such a talented young man and does not explain why the leading members of Esquirol's circle responded to Bayle's announcement of his discoveries, not only by rejecting his conclusions, but also by ridiculing his logic, his claims to originality and even his writing style. This reaction suggests that Bayle's ideas may have been troubling or even threatening to Esquirol and his followers. After all Bayle was only twenty-seven and had only recently finished his training when Royer-Collard died. Certainly such a youthful protege of a rival could have been dismissed more quietly. Paul Bercherie explains the intensity of the rejection of Bayle's ideas by suggesting that Bayle's contemporaries were misled by his enthusiastic exaggerations and wrongly believed that he was proposing pathoanatomical explanations for syndromes they were familiar with. As a consequence, he argues, they failed to recognize that Bayle's conception of general paresis as a disease was radically innovative.7 While Bayle's enthusiastic and even arrogant style no doubt provoked his critics, as Becherie suggests, the clarity of Bayle's arguments as well as the arguments of his critics leave little doubt that it was precisely because they did understand the radically innovative nature of his ideas that they reacted so violently. In 1960 Leibrand and Wettley noted that the opposition to Bayle's ideas was so strong because these ideas breached the nosology of Pinel and Esquirol.8 What they fail to note is that Bayle went beyond describing a disease which cast doubt on the existing nosology. He also advocated an alternative methodology and criterion for making disease attributions in psychiatry. In doing so Bayle challenged the credibility of the framework which gave legitimacy to the therapeutic and research activities of the dominant school of psychiatry. While later in the nineteenth century Bayle's ideas acquired considerable support, in the 1820s Bayle was an isolated figure who was ostracized because of the threat posed by his ideas.

Pinel's Research Principles The construction of the framework on which psychiatry's therapeutic and research activities were based was begun by Philippe Pinel, the founding father of French psychiatry. Pinel, who was also an important theorist in the post revolutionary reform of general medicine, was particularly concerned to establish both medicine and psychiatry on firm empirical footings and to avoid the speculative excesses of eighteenth century medical theorists. Pinel believed that these excesses could be overcome only by carefully observing symptoms, and classifying diseases according to their external manifestations, in the manner in which naturalists classified living creatures.9 A frequently cited passage from the introduction to the first edition of Pinel's Treatise on Mania, published in 1800 can be taken as a succinct statement of what I will call his research principles:

One who takes mental illness as a particular object of his researches, will make a bad choice by indulging in vague discussions about the seat of the understanding and the nature of diverse lesions; because nothing is more obscure and more impenetrable. But if one restricts oneself within broad limits, only to the study of its distinctive characteristics, as manifested by external signs, and adopts as the principle of treatment only the results of an enlightened experience, one returns to the course which must be followed in general by all parts of natural history, and by proceeding with reserve in doubtful cases, one will no longer have to fear going astray.10

In medicine Pinel's ideas had a short life, being superseded by anatomie pathologique, which sought to correlate symptoms with specific autopsy findings, and gave the latter primacy in defining the nature of disease.11 In psychiatry his views had greater longevity, albeit in modified form. What gave Pinel's ideas this longevity in psychiatry was the conviction that psychiatrists could cure a mental disease, that is eliminate its symptoms, without reference to visible anatomical lesions. The results of psychiatric treatment, not anatomical localization, formed the ultimate basis for psychiatry's diagnostic credibility. Pinel's most influential student J.E.D. Esquirol expressed this position clearly in 1816. After a discussion of the inconclusive results of patho-anatomical studies of the insane, he argued that,"happily" these results were "not indispensable" because "for the cure of madness, it is no more necessary to be familiar with its nature than it is necessary to be familiar with the nature of pain to successfully employ pain relievers and sedatives."12 The treatment on which the profession of psychiatry was built in the early nineteenth century was known as moral treatment. During the 1790s, after taking charge of the Bicetre, an asylum for insane men, Pinel observed the way in which the lay managers of that asylum influenced patients. Based on these observations he developed the idea that the insane could be influenced by moral, that is, essentially psychological, means.13 According to Pinel passions such as joy, anger, fear and sadness affected circulatory, respiratory and gastro-intestinal functions which in turn, by a process of sympathetic influence, affected the functioning of the brain. 14 While not denying that the body was implicated in madness, the psychosomatic logic of moral treatment required that insanity be understood functionally, as a nervous disorder, and not as a result of a visible lesion.15

Georget's Revision of Pinel's Ideas

For Pinel the method of classifying psychiatric diseases by describing symptoms and the method of curing these diseases by removing symptoms through moral treatment were interdependent. Together they formed a framework for research and treatment.16 To the extent that anatomie pathologique was successful in establishing symptom-lesion correlations as the basis of legitimate disease attributions it threatened the psychophysiologic rationale of moral treatment and thereby the credibility of this framework. By the third decade of the nineteenth century some psychiatrists, particularly Etienne Jean Georget, were aware of the limitations of Pinel's ideas and were at pains to revise them. To adequately understand psychiatry's reception of Bayle's discovery of general paresis one must therefore view this reception against the backdrop of Georget's work. This is especially true since Georget, before his death in 1828, was Bayle's most outspoken and articulate critic. In 1820, two years before Bayle's first work on general paresis, Georget published On Madness.17 The aim of this work, it can be argued, was to protect the rationale of moral treatment in terms consistent with anatomie pathologique. While Georget supported Pinel's rejection of eighteenth century speculative systems of pathology, approvingly quoting Pinel's statement of research principles, he took issue with both Pinel and Esquirol because they had described the phenomena of madness, "without demonstrating their source;...(and) described the facts scrupulously without connecting them to a cause."18 Rejecting religious views of the mind, Georget insisted that symptoms represented bodily changes. Moreover, influenced by the phrenologic teachings of Franz Joseph Gall, Georget sought to establish the materialist contention that the brain was the seat of the mind.19 For Georget a credible theory of the cause and cure of madness had to be consistent with anatomie pathologique. Indeed autopsy findings on insane patients formed an important section in De la Folie.20 Georget accepted the view that disease attributions had to be based on specific organ function and not on older humoral theories. As a result he sought "to fix the seat (of madness), to demonstrate the source of the disorders produced, as one does in all other diseases..."21 However,true to his psychophysiological views on madness, Georget also insisted that it was "less on its physical dispositions than on its functions that one must form the divisions of the nervous system; it is thus always that anatomy must follow physiology."22 Georget rejected Pinel's suggestion that the seat of madness might be found in disorders of the intestines.23 Instead he argued that madness was a primary or idiopathic disease of the brain. As a result moral influences could be seen as causing madness by directly influencing the brain and moral treatment as curing madness in the same direct manner. Psychiatrists were, like other doctors, responsible for diseases of a specific organ and, moreover, they had an effective treatment for disorders of that organ.For Georget this was the basis of psychiatry's legitimacy as a medical specialty. If insanity were merely secondary,or sympathetic, to a disorder in another part of the body, he argued, this legitimacy would be challenged. He expressed this opinion as follows:

If (insanity) is idiopathic, the organ from which all the disorders emanate, merits the attention of the doctor: to re-establish its functions,... but if it is sympathetic, it is necessary most particularly to address oneself to its cause, to the distant affection which produces and maintains it; otherwise one can only palliate, ... The treatment of madness must thus especially be founded on the state of the brain...24

Aware that some patients seen in asylums were not curable by moral treatment and that some had lesions of the brain and other parts of the body, Georget protected the psychophysiological rationale of moral treatment by adopting what has been called a dualist position.25 He drew a sharp distinction between acute delirium (le delire aigu) and madness proper. The former he regarded as secondary to intoxications, head trauma and disorders in other organs. It was likely to be both incurable and associated with lesions of the brain or other organs. Madness proper was defined in this scheme as an idiopathic disorder that was not associated with visible lesions but was due to physiologic changes in the brain. It was caused exclusively by the interaction of predisposing factors, such as heredity, and precipitating moral or emotional factors such as grief and fear. It was curable by moral treatment. This distinction between le delire aigu and madness proper was supported by Georget's review of autopsy findings among the insane. On the basis of this review. Georget argued for the value of negative as well as positive autopsy findings. He supported his view that madness was an idiopathic or physiological disorder of the brain by pointing to the fact that autopsies done on patients with madness proper revealed no consistent lesions in the brain.26 Because such lesions could not be found, the success of the direct treatment of madness by moral means, rather than anatomie pathologique, could remain the basis of psychiatry's scientific and professional credibility.

Bayle and the Discovery of General Paresis

Before entering psychiatry, Antoine Bayle had already studied with Rene-Theophile-Hyacinthe Laennec, who was one of the leading advocates of anatomie pathologique, as well as a friend and associate of Antoine's uncle Gaspard-Laurent Bayle.27 Antoine Bayle greatly admired these men and sought to emulate them. He also believed that their ideas were in direct conflict with Pinel's. The younger Bayle saw the teaching of medicine at the beginning of the nineteenth century as divided between two schools, that of Pinel and that of Corvisart, with whom Laennec and his uncle had studied. Of Pinel's teachings in medicine he wrote that, "one could not at all hide the fact that they could lead one astray by making one neglect the organic causes of diseases, by focusing too exclusively on derangements of function."28 According to Bayle, Laennec appreciated this difficulty and felt that the best foundation for medicine was the disciplined search for lesions.29 It is clear that in the conflict which he saw between the medical teachings of Pinel and those of Corvisart, Laennec and the elder Bayle, Antoine Bayle identified with the latter. We do not know just why Bayle entered into psychiatry. Postel and Semelaigne suggest that when Bayle was offered a position in psychiatry by one of his uncle's friends, it was only his poverty which led him to accept. However, we also know that the elder Bayle had written that anatomie pathologique:

had not made enough progress toward sufficiently clarifying the diverse genres of organic diseases: many degenerations which present different structures are still confounded and linked under the same designation. It will be difficult for a long time to remedy these difficulties, because few doctors are placed in a position favorable to making autopsies... to remedy these difficulties... nothing would be more advantageous than an exact monograph on each of the orders or genres which compose the class of (organic diseases).30

While the promise of economic security may have motivated Antoine Bayle to enter psychiatry in 1818, it also seems likely that he saw a position at a psychiatric institution as an opportunity to act on his uncle's suggestion. Certainly psychiatric hospitals at that time presented a rich field for autopsy studies.The younger Bayle began his brief career in psychiatry as an interne at the Royal Asylum for the Insane at Charenton, where he studied under A-A Royer-Collard. Evidence suggests that Bayle and Royer-Collard's relationship was a close one. Both were Royalists; and Bayle's praise for Royer-Collard as a mentor was lavish.31 While at Charenton, Bayle focused his efforts on clinico-pathological research. He performed a great number of autopsies, and when writing about treatment, he cited Royer-Collard's experience rather than his own.32 The substantial prevalence of paralytic symptoms among the insane, as well as the fatal prognostic implications of a diagnosis of paralysis were well known when Bayle entered Charenton. In 1816 Esquirol had noted that a majority of a series of two hundred and thirty patients suffering from dementia were also afflicted with paralysis.33 At about the same time he gave a detailed description of the physical symptoms of this paralysis and noted that death could soon be expected following its diagnosis.34 Paralysis had also been observed at Charenton. Trouseau noted that this diagnosis could be found frequently in the case books of that asylum before Bayle arrived.35 At the time of Bayle's research, the prevailing interpretation of the occurrence of paralytic symptoms among the insane was that these symptoms represented a complication of the insanity. This had been Esquirol's view for some time. In his discussion of madness in the authoritative Dictionnaire des Sciences Medicales, Esquirol, without any particular justification, simply listed la paralysie as a complication along with la phthisie and le scorbut.36 It appears that he regarded it as a complication because the physical symptoms of paralysis occurred after the mental symptoms of insanity and because he could not correlate these symptoms with any particular form of insanity. It is also probable that Esquirol's conception of insanity as a cluster of mental symptoms precluded his seeing a physical symptom like paralysis as other than a complication. It was with this conception of insanity as a cluster of symptoms as well as Esquirol's interpretation of paralysis as a complication that Bayle took issue. Bayle first announced his views about paralysis in his medical thesis in 1822, when he was only twenty four years old. This work presented the results of Bayle's patho-anatomical researches at Charenton. It was divided into three chapters each devoted to describing cases of insanity which were secondary to disorders located outside of the brain. While the chapters on insanity secondary to gastro-enteritis and gout have been forgotten, the fact that they were presented alongside of the chapter on general paresis suggests that Bayle's overall purpose was to establish the clinico-pathological foundation of the idea of symptomatic insanity. Bayle's choice of the autopsy finding "Chronic Arachnitis," rather than either the physical or mental symptoms, for the title of his chapter on general paresis also suggests his angle of vision. This chapter contained the main features of Bayle's ideas on the relationship between the mental symptoms of insanity, paralysis and the results of autopsy .37 It ambitiously rejected Esquirol's view that paralysis was a complication of insanity. Instead Bayle argued that paralysis was only one facet of a complex disorder which included both mental and physical symptoms and which arose secondary to a chronic inflammation of the arachnoid lining of the brain. He described this disorder as occurring in three stages. The first was characterized by a mild paralysis, particularly affecting speech, and a monomania, particularly a monomania involving grandiose ideas. The second stage was characterized by a generalized mania and a worsening of the paralysis and the third by dementia and severe paralysis. In each of six cases, he detailed the clinical course and noted the constant presence at autopsy of an inflammation of the arachnoid membrane. Following the logic of Laennec's anatomie pathologique, he reasoned that all of those symptoms associated with constant pathological findings ought to be regarded as part of a single disorder, and that those pathological finding ought to be regarded as the immediate cause of the symptoms. The first of these cases, Claude-Francois L., was admitted to Charenton in October 1818, shortly after Bayle began his work there. This case provides an example of Bayle's approach to explaining psychiatric diseases. On admission this patient was "in a demented state, with ideas that are predominantly ambitious, and with his partial paralysis ...advanced," By the time of his death, this patient provided Bayle with a fully developed picture of the clinical course of the disease. Finding an inflammation of the arachnoid lining of the brain on autopsy, Bayle concluded that the full course of this patient's illness could be explained by this lesion. After presenting the autopsy findings he asked rhetorically, "Does not this observation prove that the disorder of the intellectual faculties was the symptom of a chronic arachnitis and not an essential delire." 38 Pursuing the conclusion that the lesions he has found are "the anatomic characteristics of chronic mental disturbance," Bayle attempted to explain in detail how these lesions resulted in the particular symptoms observed. Claude-Francois L.'s symptoms began with a loss of consciousness which Bayle argued was due to sudden congestion of the blood vessels of the pia mater and the cerebrum. Bayle explained the difficulty with speech, staggering gait, agitation and monomania which occurred during the second period of the disease as due to the increasing inflammation of the arachnoid lining and an outpouring of serous fluid which pressed on the brain. In the third period the trembling, loss of sphincter control and complete dementia were explained in the same manner as due to chronic inflammation of the arachnoid and increasing pressure on the brain from serous exudate.39

Georget and Bayle

Bayle was aware of Georget's book when he wrote his medical thesis. He noted that Georget's views differed from Pinel's in that Georget regarded madness as "always an idiopathic cerebral disorder." He considered opinions such as Georget's, however, as "too exclusive." It seemed to Bayle that "any physician who is not dominated by any preconceived ideas... will not be able to deny that mental disease is most often idiopathic but sometimes he will find it symptomatic."40 This, he added was the opinion of Royer-Collard. While Bayle's thesis did receive public notice, it did not provoke great controversy.41 In part this was due to Bayle's limiting himself to announcing an exception to the principle of madness as an idiopathic brain disease. The year 1822 was, however, also a year of considerable political turmoil in French medicine. In October of that year the Restoration government dismissed the largely republican faculty of the Paris medical school and replaced them with royalist sympathizers. While this political interference may have hurt the teaching of medicine, it also resulted in the elevation of Laennec, who like Bayle was a royalist, to a position of power.42 This changing political climate must have emboldened Bayle. In 1824 Bayle participated in founding the Revue Medicale, a journal which served as a vehicle for his ideas for a number of years.43 In 1825 he published a theoretical statement of his views in this new journal. This virtual manifesto was provocatively titled "A New Doctrine of Mental Disease." 44 This was strictly a theoretical statement published without data, which Bayle promised to present in a later treatise.45 The most obvious feature of this "new doctrine" was Bayle's ambitious reversal of his earlier position that most mental illness is idiopathic. He now insisted that "sometimes, but very rarely" madness is due to strictly psychological factors affecting the mind.46 In the greatest number of cases, he insisted, madness is due to a physical lesion, most often a chronic inflammation of the meninges, but sometimes a specific or sympathetic irritation of the brain. Another feature of Bayle's "new doctrine" was methodologic. Bayle explicitly rejected Pinel's statement of research principles.47 He also rejected and reversed the approach to symptom-lesion correlations used by those "modern authors" who concluded that one cannot account for the symptoms of madness through organic lesions. According to Bayle they reached this false conclusion because they tallied the frequencies of various symptoms and only then attempted to correlate these frequencies with the frequencies of various lesions found upon autopsy. By beginning with symptom clusters and looking for lesions they failed "to see in the history of a particular patient the organic lesions in opposition to the symptoms which correspond to them..." Consequently they lost the opportunity to explain the symptom through the lesion. Bayle, by contrast, concluded that a disease was present in a particular case when he found a lesion. He then collected a great number of individual histories of madness and linked those with the greatest similarity in a manner which allowed him to arrive at a general doctrine.48 Unlike his thesis, Bayle's "new doctrine" did provoke criticism. Among those provoked was Georget, who, it is likely, spoke for Esquirol and his circle.49 Georget noted that Bayle had dramatically changed his opinions. In 1822, he pointed out, Bayle had agreed with the view that madness is most often idiopathic and only sometimes symptomatic, while in 1825 he reversed himself. "From 1822 to 1825," Georget exclaimed, "what a change!!" Noting that Bayle had been a student at Charenton in 1822 and had not worked there since 1822, Georget went on to suggest that Bayle's earlier views were perhaps only flattery addressed at the men in power at that time.50 He acknowledged that his critique of Bayle was "severe," but justified this severity by what he called Bayle's " exaggerated pretension."51 Had Bayle not announced a "New Doctrine," but rather stuck to his earlier claim to have found only an instance of insanity caused by an inflammation of the meninges, Georget noted that he would not have taken up his pen.52 Georget treated Bayle's "new doctrine" as nothing more than a series of speculative assertions or what he sarcastically called "novelties." Consequently he contented himself with demonstrating that in presenting each of these novelties Bayle was either inconsistent, vague or unoriginal. Of Bayle's claim, for example, that "in one case in five among men and one case in thirty or thirty-five among women... madness is the result of a chronic inflammation of the meninges," Georget rightly noted that the observation of such an inflammation was not new.53 He added that Pinel and Esquirol considered such an inflammation, not as the cause, but as a complication of madness. "It is a question," he asked rhetorically, "of knowing who is right between these doctors and M.Bayle."54 What galled Georget most about Bayle's "new doctrine," however, was Bayle's assertion that "all the doctors who have written before him, all of whom he calls excellent observers," had failed to use the proper method of reaching conclusions about the relationship between symptoms and lesions.55 No doubt regarding himself as one of these excellent observers, Georget did not discuss the substance of Bayle's methodologic position. Instead he concluded this review by dismissively expressing doubt that Bayle could back up his theory with proof.56 The next year Bayle accepted Georget's challenge and published a six hundred page treatise on chronic meningitis, which included a detailed description of ninety cases. He repeated his claim that, "the majority of mental illnesses are the symptom of a primary chronic inflammation of the membranes of the brain."57 As in his thesis he attempted to explain both mental and physical symptoms through the effects of chronic meningitis. He accepted the objection that in "the actual state of science" the question of how an inflammation of the linings of the brain could result in dominant ideas of ambition was "almost insoluble."58 Nonetheless he was willing to conjecture. Rejecting phrenological explanations, he argued that meningitis might be seen as predisposing a patient to certain ideas in the same way as gastritis predisposed patients to hypochondria and pulmonary tuberculosis to unfounded optimism.59 If individuals struck with chronic meningitis were imperious, vain, prideful and ambitious before becoming ill, then "everything unites to give their delusions an analogous character."60 Georget also reviewed this book. He was as sarcastic as before accusing Bayle of writing a book which was "six times too long, the reading of which was as fatiguing as possible."61 He did, however, summarize Bayle's theory and his data lucidly and accurately. Georget was not, as Becherie has suggested, misled into believing that Bayle was merely proposing a pathological anatomy for generally familiar syndromes.62 Rather, he was opposed to what he regarded as the faulty logic of Bayle's accepting autopsy findings as signifying the presence of disease and reasoning from these findings to explain symptoms.Georget based his argument on the first two cases presented in Bayle's book. The first, Claude-Francois L., was a reprint of the same case Bayle had presented in his thesis. This patient demonstrated all three stages of the illness. The second patient choked to death early in the course of the illness. Finding the arachnoid slightly inflamed in the second case Bayle counted it as an example of general paresis, even though the patient presented with monomania but not with paresis. For Bayle these two cases presented autopsy findings at different stages of the same disorder. For Georget treating these two cases as due to the same disease was a failure of logic. According to Georget, Bayle:

didn't have a method of proceeding to arrive at the demonstration of such an opinion; it was necessary to present simple cases, where the phenomena have been observed separately; there are among the insane, ambitious monomanias without paralysis, and paralyses without ambitious monomanias, whatever M. Bayle says to the contrary; it is in comparing the autopsy results from one or another illness that one can perhaps succeed in distinguishing them."63

For Georget the presence of an illness was determined by the careful observation of symptoms. Only when such an illness had been defined did looking for causes make sense. To emphasize this Georget concluded this review by suggesting that bias had prevented Bayle from abiding by Pinel's research principles. "It is necessary," Georget argued, "to assemble a certain number of facts, observed and researched with exactitude, it is necessary to compare them, and to derive all natural inductions; it is necessary to study disorders of movement among the insane, ambitious monomania and dementia, and not chronic meningitis, except to conclude in the end that the affection is the cause of the enumerated symptoms."64

Calmeil

In the same year that Bayle published his treatise Louis Calmeil, like Bayle, a physician at Charenton, but like Georget a student of Esquirol, also published a treatise entitled On Paralysis, Considered among the Insane. Calmeil's several references to Bayle throughout this book, make it clear that he was not merely announcing his own findings, but also responding to Bayle's claims.65 On the opening page of his book Calmeil makes it clear that his opposition to Bayle was stimulated by Bayle's "wanting to establish the extraordinary principle that the majority of the time mental illness has for its immediate cause a physical lesion of the meninges."66 Calmeil reported sixty cases of paresis with autopsy findings on thirty nine. His method of tracing the connections between clinical and post mortem findings differed from Bayle's. He took symptoms, "one by one," observed their development in the manner approved by Pinel and Georget and then predicted what he would find on opening the body.67 In contrast to Bayle's observation of constant pathological findings associated with paralysis, Calmeil found a great variety of lesions at autopsy. Because he found such a variety of lesions, he argued that these lesions could not "sufficiently explain the symptoms observed during life."68 After reviewing the various mental symptoms associated with paralysis, he insisted that one deceives oneself if one concludes that the progression of these symptoms follows the neat three stage model proposed by Bayle.69 Georget reviewed Calmeil's book, predictably praising him for his wisdom and restraint.70 Bayle, on the other hand, responded to Calmeil as sarcastically as Georget had responded to him. Calmeil had concluded that, "it is a chronic inflammation which gives rise to general paralysis, by inducing in the brain a modification which we have not been able to appreciate." Bayle responded by asking rhetorically, "what is this chronic inflammation which has none of the characteristics of inflammations...," that is, does not present with visible lesions.71 The differences between Bayle's and Calmeil's autopsy findings were not a matter of simple empiricism. Laennec had emphasized the importance of inflammatory lesions on the linings of various organs as one of the principle findings of pathological anatomy.72 In defending himself against Calmeil's argument that only an inflammation of the brain, not one of its linings could result in madness, Bayle later suggested that his view of the pathogenic significance of chronic meningitis was supported by its striking analogy with the pathogenic significance accorded to inflammations of other body linings, as for example pleurisy.73 In opening the bodies of the insane Bayle saw what he saw through lenses provided by Laennec. Calmeil, in turn, also saw what he saw through lenses provided him by Pinel.

Monomania

Georget and Calmeil were at such pains to refute Bayle, not only because the logic of his method of linking symptoms and lesions turned theirs on its head or because his claims for the explanatory power of his findings were so broad, but also because the diagnosis of general paresis threatened the disease status of monomania and consequently its ideological value for psychiatry. Originally described by Esquirol, the diagnosis of monomania referred to a symptom complex including exalted mood, increased energy and a preoccupation with a particular idea.74 According to Esquirol, monomania was not merely a disease but it was "of all diseases, the one whose study offers the broadest and most profound subject for meditation:the study of it embraces... that of civilization."75 Moreover, according to Goldstein, Esquirol believed that the fluid society that was the legacy of the Revolution produced its own peculiar monomania, that of overweening ambition. The ideological significance of the idea that changes in the form of monomania reflected changes in the passions of civilization can be seen in Esquirol's suggestion, made in 1822, that a physician's "familiarity with the causes and character of the regnant madnesses" might allow him to furnish the government with the most certain elements of a moral statistics of population.76There is no evidence to suggest that Bayle's aim was to undermine the diagnosis of monomania, even though his conservative religious views probably made him uncomfortable with the implications of this diagnosis.77 Nonetheless by treating monomania, particularly ambitious monomania, as merely a symptom of an inflammation of the meninges, Bayle not only relegated monomania to the status of a symptom, he also undermined the social psychological significance of that disease category. In this light Georget's argument against the constant association of monomania and paralysis can also be seen as an effort to preserve the independent status of monomania as a disease.

Conclusion

In the early nineteenth century Pinel's research principles, which had so effectively separated modern psychiatry from the speculative excesses of earlier centuries, were confronted with the challenge of a new way of thinking about disease. Both Antoine-Laurent-Jesse Bayle and Etienne Georget were aware of the inadequacies of Pinel's position. Both attempted to use autopsy findings to establish psychiatric research on firmer footing. Georget attempted to preserve the Pinel's descriptive approach to symptoms and with it the role of moral treatment in legitimizing psychiatric disease attributions. Bayle, in contrast, rejected Pinel's position outright. Instead he sought to demonstrate, through the discovery of general paresis, the primacy of anatomie pathologique as a methodology and a set of assumptions about disease. Bayle's far reaching claims for the significance of his discovery can be understood in terms of his ambitious advocacy for the approach to disease which his uncle and his mentor stood for. For Georget, however, Bayle's insistence that "the majority of mental illnesses are the symptom of a primary chronic inflammation of the membranes of the brain" threatened the primary role he hoped to establish for brain function as the cause of madness. The united opposition of members of Esquirol's circle to Bayle and his ideas sealed his fate. After Laennec died in 1826, Bayle retired not only from psychiatry but also from clinical medicine, becoming a librarian and bibliographer. Perhaps Bayle, in extending his uncle's legacy to psychiatry, had done all he had intended to do. Georget and Calmeil's reactions to Bayle set the tone for subsequent discussions of Bayle by other authors. As late as 1838 Esquirol in his Maladie Mentale echoed Georget's contention that monomania and paralysis were not constantly associated.78 Even as Bayle's discovery that general paresis of the insane was a distinct disease, involving both mental and physical symptoms and associated with demonstrable pathological findings, came to be accepted, almost ritual references to Bayle's pretensions and exaggerations were regularly expressed. As late as 1855 his claims to priority in the discovery of general paresis were still being challenged.79 It is certainly true that Bayle was provocative and even pretentious in his style. It is also true that Bayle was an outsider whose views would understandably be viewed with suspicion by members of Esquirol's circle. It was, however, the fact that Bayle's ideas threatened the credibility of the framework which which gave legitimacy to the research and therapeutic activities of Esquirol's school, that led to his fate.

72.This is not surprising in that pathological anatomy during the early nineteenth century relied only on macroscopic findings and so many of the people whose bodies were examined had died of inflammatory diseases. Maulitz, Morbid Appearances (n.42), pp.19-25.